A large portion of deaths in the U.S. occurs in the intensive care unit (ICU) or after a stay in the ICU. There is mounting evidence of problems in the quality of care these patients and their families receive, although much of this evidence comes from academic medical centers. This proposal is a competitive renewal of our previous 2-year R01 that examined the quality of clinician-family communication about end-of-life care in the ICU. In the prior grant, we identified specific shortcomings in patient-clinician communication and discovered that an intervention to improve this communication cannot exclusively target the ICU family conference. Based on the findings of the prior grant, this competitive renewal application proposes to evaluate an organizational, nurse-focused intervention to improve end-of-life care in the ICU with 5 components: 1) nurse, physician, and respiratory therapist education regarding the principles and practice of palliative care in the ICU; 2) academic detailing nurse, physician, and respiratory therapist directors identifying and addressing local barriers to quality end-of-life care; 3) implementation of standardized "withdrawal of life support" order forms and family pamphlets; 4) guidance from local nurse, physician, and respiratory therapist champions; and 5) feedback of local quality improvement data in comparison to the aggregated ratings at the other sites. The intervention will be evaluated in a randomized, controlled trial with the hospital as the unit of randomization and the hospital and the ICUs as the target of the intervention. The outcomes include: a) the previously validated "Quality of Dying and Death" questionnaires assessed by families and nurses, b) satisfaction with care assessed by the families and nurses, and c) indicators of quality of care assessed by nurses and from medical record review. The primary outcome is family-assessed "Quality of Dying and Death". Statistical analyses use generalized estimating equations to allow analysis of patient-level data while controlling for the clustering within units and hospitals. The goal of this proposal is to demonstrate the effectiveness of a generalizable, multi-faceted, nurse-focused quality improvement project designed to improve end-of-life care in the ICU.